Nokea
The client is on enoxaparin (Lovenox) for DVT prophylaxis. What is the most important lab value to monitor?
- A. Platelet count
- B. PT/INR
- C. aPTT
- D. Hemoglobin
Correct Answer: A
Rationale: The correct answer is A: Platelet count. Enoxaparin is a low molecular weight heparin that can cause thrombocytopenia, a potentially serious side effect. Monitoring platelet count is crucial to detect any decrease, as it may increase the risk of bleeding. PT/INR and aPTT are used to monitor warfarin and heparin, respectively, not enoxaparin. Hemoglobin monitoring is important for anemia but not the most crucial lab value in this scenario.
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Discuss the strategies to prevent ventilator-associated pneumonia.
- A. Oral hygiene
- B. Elevation of head
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Prevention includes maintaining oral hygiene and elevating the head of the bed.
If Mr. Smith is admitted with pericarditis with effusion and shows dyspnea, tachycardia, distended neck veins, and arterial hypotension, your evaluation of the situation would be that
- A. These are signs of cardiac tamponade
- B. These signs are to be expected
- C. He needs to be placed flat in bed to relieve the problem
- D. He has overexerted himself and needs to rest
Correct Answer: A
Rationale: Cardiac tamponade compromises cardiac function.
Mrs. Payer's care plan during the acute phase following MI should include attention to such psychologic aspects as fear, stress, and hopefulness. Therapeutic goals from the time of admission must be geared to
- A. acceptance
- B. rehabilitation
- C. slowing down
- D. dependence
Correct Answer: A
Rationale: Acceptance facilitates adaptation to illness.
A patient who underwent a percutaneous, transluminal coronary angioplasty four weeks ago has a subsequent ejection fraction of 30%. The patient returns for a follow-up visit. Examination reveals lungs that are clear on auscultation and slight pedal edema. The patient's medications are digoxin (Lanoxin), furosemide (Lasix), enalapril maleate (Vasotec), and aspirin. The patient reports a 5 lb (2.27 kg) weight gain over the past two days. The cardiac-vascular nurse's initial action is to:
- A. document the weight and reassess the patient at the next session.
- B. inquire about the patient's medication compliance.
- C. notify the patient's physician.
- D. review the patient's most recent nuclear scan.
Correct Answer: B
Rationale: Weight gain and pedal edema suggest fluid retention, so assessing medication compliance is essential.
A patient recently had a cardiac catheterization via right-radial approach and now has a compression device in place. The patient reports numbness and pain in the right hand. The cardiac-vascular nurse notes a diminished pulse, with a cool and cyanotic hand. The nurse:
- A. calls the physician.
- B. performs an Allen test.
- C. reduces the pressure on the puncture site.
- D. uses the Doppler ultrasound to assess for pulse signals.
Correct Answer: C
Rationale: Reducing pressure on the puncture site is necessary to restore blood flow to the hand.